Transjugular intrahepatic portosystemic shunt for the management of acute variceal hemorrhage

Acute variceal hemorrhage,a life-threatening condition that requires a multidisciplinary approach for effective therapy,is defined as visible bleeding from an esophageal or gastric varix at the time of endoscopy,the presence of large esophageal varices with recent stigmata of bleeding,or fresh blood visible in the stomach with no other source of bleeding identified.Transfusion of blood products,pharmacological treatments and early endoscopic therapy are often effective;however,if primary hemostasis cannot be obtained or if uncontrollable early rebleeding occurs,transjugular intrahepatic portosystemic shunt(TIPS)is recommended as rescue treatment.The TIPS represents a major advance in the treatment of complications of portal hypertension.Acute variceal hemorrhage that is poorly controlled with endoscopic therapy is generally well controlled with TIPS,which has a 90%to 100%success rate.However,TIPS is associated with a mortality of 30%to 50%in such a setting.Emergency TIPS should be considered early in patients with refractory variceal bleeding once medical treatment and endoscopic sclerotherapy failure,before the clinical condition worsens.Furthermore,admission to specialized centers is mandatory in such a setting and regional protocols are essential to be organized effectively.This review article discusses initial management and then focuses on the specific role of TIPS as a primary therapy to control acute variceal hemorrhage,particularly as a rescue therapy following failure of endoscopic approaches.

Endovascular management of visceral artery aneurysms: When to watch, when to intervene?

Visceral artery aneurysms(VAA) include splanchnic and renal artery aneurysms. They represent a rare clinical entity, although their detection is rising due to an increased use of cross-sectional imaging. Rupture is the most devastating complication, and is associated with a high morbidity and mortality. In addition, increased percutaneous endovascular interventions have raised the incidence of iatrogenic visceral artery pseudoaneurysms(VAPAs). For this reason, elective repair is preferable in the appropriately chosen patient. Controversy still exists regarding their treatment. Over the past decade, there has been steady increase in the utilization of minimally invasive, non-operative interventions, for vascular aneurysmal disease. All VAAs and VAPAs can technically be fixed by endovascular techniques but that does not mean they should. These catheter-based techniques constitute an excellent approach in the elective setting. However, in the emergent setting it may carry a higher morbidity and mortality. The decision for intervention has to take into account the size and the natural history of the lesion, the risk of rupture, which is high during pregnancy, and the relative risk of surgical or radiological intervention. For splanchnic artery aneurysms, we should recognize that we are not, in reality, well informed about their natural history. For most asymptomatic aneurysms, expectant treatment is acceptable. For large, symptomatic or aneurysms with a high risk of rupture, endovascular treatment has become the firstline therapy. Treatment of VAPAs is always mandatory because of the high risk of rupture. We present our point of view on interventional radiology in the splanchnic arteries, focusing on what has been achieved and the remaining challenges.

Novel imaging biomarkers of response to transcatheter arterial chemoembolization in hepatocellular carcinoma patients

Hepatocellular carcinoma common cause of cancer death （HCC） is the third most worldwide （1）. Most patients present with intermediate or advanced disease that is not amenable to curative treatment, and the median survival in this group is 6-8 months （2）. Several studies and well- designed randomized trials have shown a positive effect of transcatheter arterial chemoembolization （TACE） on patient outcome and survival （3-8）. As nicely described in the present article from Wring et al., assessment of tumor response is of extreme importance in patients undergoing locoregional treatments of liver cancer （9）. Early assessment of the effectiveness of TACE and monitoring of tumor response are paramount to the identification of treatment failure, guidance of future therapy, and determination of the interval for repeat treatment.

Interventional radiology therapies for liver cancer

Hepatocellular carcinoma(HCC)is the fifth most frequently found primary malignant tumor in the world.Hepatic surgery and liver transplantation are considered optimal for the curative treatment of HCC.However,only 15-20%of HCCs may be surgically treated.Most of the surgically-non-eligible patients have to receive locoregional image-guided interventional treatments including intra-arterial and percutaneous ablative therapies.The goal of this paper is to review these interventional oncology approaches.Ablative therapeutic approaches include chemical therapies(such as ethanol or acetic acid injection),and thermal therapies(such as radiofrequency ablation,laser-induced thermotherapy,microwave ablation,cryoablation,and high-intensity focused ultrasound ablation).Catheter-based therapies include embolotherapy/chemotherapy-based treatments(such as transcatheter arterial chemoembolization,bland embolization,transcatheter arterial chemoinfusion,and chemoembolization with drug-eluting beads),and radiotherapy-based treatments(such as radioembolization with yttrium-90 and injection of iodine-131-labeled lipiodol).As a result of the technical development of locoregional approaches for HCC during the recent decades,the range of combined interventional therapies has been continuously extended.In this article,an evidence-based approach will be used to review the current role of interventional radiology therapies in the management of unresectable HCC.